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Partain DK, Santivasi WL, Kamdar MM, Moeschler SM, Tilburt JC, Fischer KM, Strand JJ. Attitudes and Beliefs Regarding Pain Medicine: Results of a National Palliative Physician Survey. J Pain Symptom Manage 2024; 68:115-122. [PMID: 38677489 DOI: 10.1016/j.jpainsymman.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 04/04/2024] [Accepted: 04/12/2024] [Indexed: 04/29/2024]
Abstract
CONTEXT Pain is a prevalent symptom in patients with serious illness and often requires interventional approaches for adequate treatment. Little is known about referral patterns and collaborative attitudes of palliative physicians regarding pain management specialists. OBJECTIVES To evaluate referral rates, co-management strategies, and beliefs of palliative physicians about the value of Pain Medicine specialists in patients with serious illness. METHODS A 30-question survey with demographic, referral/practice, and attitudes/belief questions was mailed to 1000 AAHPM physician members. Responses were characterized with descriptive statistics and further analyzed for associations between training experiences, practice environment, and educational activities with collaborative practice patterns and beliefs. RESULTS The response rate was 52.6%. Most survey respondents had initial board certification primarily in internal medicine (n = 286, 56%) or family medicine (n = 144, 28%). A minority of respondents had completed a formal ABMS Hospice and Palliative Medicine fellowship (n = 178, 34%). Respondents had been in practice for a median of nine years, (range 1-38 years) primarily in community hospitals (n = 249, 47%) or academic hospitals (n = 202, 38%). The variables best associated with collaborative practices and attitudes was practice in an academic hospital setting and participation in regular joint academic conferences with pain medicine clinicians. CONCLUSION This study shows that Palliative Care physicians have highly positive attitudes toward Pain Medicine specialists, but referrals remain low. Facilitating professional collaboration via joint educational/clinical sessions is one possible solution to drive ongoing interprofessional care in patients with complex pain.
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Affiliation(s)
- Daniel K Partain
- Division of Community Internal Medicine (D.K.P., J.J.S.), Geriatrics, and Palliative Care, Mayo Clinic, Rochester, Minnesota, USA.
| | - Wil L Santivasi
- Department of Medicine (W.L.S.), Duke University School of Medicine, Durham, North Carolina, USA
| | - Mihir M Kamdar
- Section of Palliative Care and Geriatric Medicine (M.M.K.), Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Anesthesia Pain Medicine (M.M.K.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Susan M Moeschler
- Division of Pain Medicine (S.M.M.), Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jon C Tilburt
- Department of General Internal Medicine (J.C.T.), Mayo Clinic, Scottsdale, Arizona, USA
| | - Karen M Fischer
- Quantitative Health Services (K.M.F.), Mayo Clinic, Rochester, Minnesota, USA
| | - Jacob J Strand
- Division of Community Internal Medicine (D.K.P., J.J.S.), Geriatrics, and Palliative Care, Mayo Clinic, Rochester, Minnesota, USA
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2
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Williams JM, Berg LC, Clayton HM, Kirsch K, Marlin D, Randle H, Roepstroff L, van Oldruitenborgh-Oosterbaan MS, Weishaupt MA, Munsters C. A Delphi Study to Determine International and National Equestrian Expert Opinions on Domains and Sub-Domains Essential to Managing Sporthorse Health and Welfare in the Olympic Disciplines. Animals (Basel) 2023; 13:3404. [PMID: 37958159 PMCID: PMC10650931 DOI: 10.3390/ani13213404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/29/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
The public is increasingly questioning equestrianism's social license to operate. While the focus historically centered on horseracing, increased scrutiny is now being placed on how dressage, showjumping, and eventing are addressing equine management and welfare concerns. Nominated equestrian federation and equestrian organization experts (n = 104) directly involved in international and/or national-level horse sports took part in a four-stage, iterative Delphi to obtain consensus on what factors should be considered essential to manage sporthorse health and welfare. Five core domains were agreed as essential: training management, competition management, young horse management, health status and veterinary management, and the horse-human relationship. Two further domains: stable and environmental management, and welfare assessment were rated as important but not essential, as most respondents felt that these areas were already managed well. Participants felt increased education and guidance combined with further policy development and regulation are needed to support stakeholders to optimize sporthorse management. An appetite to engage with research to generate evidence that promotes sporthorse welfare was evident. The development of a sporthorse welfare charter and evidence-based guidelines to inform the management and monitoring of sporthorses' health and welfare are recommended to provide horses with a good life and to safeguard the future of equestrian sports.
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Affiliation(s)
| | - Lise C. Berg
- Department of Veterinary Clinical Science, University of Copenhagen, Hoejbakkegaards Alle 5, 2630 Taastrup, Denmark;
| | - Hilary M. Clayton
- Department of Large Animal Clinical Sciences, Michigan State University, East Lansing, MI 48824, USA;
| | - Katharina Kirsch
- Department Sensors and Modeling, Leibniz Institute for Agricultural Engineering and Bioeconomy (ATB), Max-Eyth Allee 100, 14469 Potsdam, Germany;
| | - David Marlin
- AnimalWeb Ltd., Tennyson House, Cambridge CB4 0WZ, UK;
| | - Hayley Randle
- School of Agricultural, Environmental and Veterinary Sciences, Charles Sturt University, Wagga Wagga, NSW 2678, Australia;
| | - Lars Roepstroff
- Department of Anatomy, Physiology and Biochemistry, Faculty of Veterinary Medicine and Animal Sciences, Swedish University of Agricultural Sciences, SE-75007 Uppsala, Sweden;
| | | | - Michael A. Weishaupt
- Equine Department, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland;
| | - Carolien Munsters
- Equine Integration B.V., Groenstraat 2c, 5528 NS Hoogeloon, The Netherlands;
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Yusufov M, Pirl WF, Braun I, Sannes T, McHugh RK. Toward a Psychological Model of Chemical Coping with Opioids in Cancer Care. Harv Rev Psychiatry 2023; 31:259-266. [PMID: 37948154 PMCID: PMC11060627 DOI: 10.1097/hrp.0000000000000384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
LEARNING OBJECTIVES AFTER PARTICIPATING IN THIS CME ACTIVITY, THE PSYCHIATRIST SHOULD BE BETTER ABLE TO • Outline the risk factors involved with opioid accessibility in patients receiving treatment for cancer.• Identify factors to address in order to mitigate risk for opioid misuse during cancer care. ABSTRACT Most patients with advanced cancer receive treatment for related pain. Opioid accessibility, however, is a risk factor for misuse, which can present care challenges and quality-of-life concerns. There is a lack of consistent universal screening prior to initiation of opioid prescribing. One crucial issue in treating this population is adequately identifying and mitigating risk factors driving opioid misuse. Drawing on theory and research from addiction science, psychology, palliative care, and oncology, the presented conceptual framework suggests that risk factors for opioid misuse during cancer care can be stratified into historical, current, malleable, and unmalleable factors. The framework identifies necessary factors to address in order to mitigate risk for opioid misuse during cancer care, and offers key directions for future research.
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Affiliation(s)
- Miryam Yusufov
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology & Palliative Care, 450 Brookline Avenue, Boston, MA 02215
- Harvard Medical School, Boston, MA 02115
| | - William F. Pirl
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology & Palliative Care, 450 Brookline Avenue, Boston, MA 02215
- Harvard Medical School, Boston, MA 02115
| | - Ilana Braun
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology & Palliative Care, 450 Brookline Avenue, Boston, MA 02215
- Harvard Medical School, Boston, MA 02115
| | - Timothy Sannes
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology & Palliative Care, 450 Brookline Avenue, Boston, MA 02215
- Harvard Medical School, Boston, MA 02115
| | - R. Kathryn McHugh
- McLean Hospital, Center of Excellence in Alcohol, Drugs, and Addiction, 115 Mill Street, Belmont, MA 02478
- Harvard Medical School, Boston, MA 02115
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4
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Cherny NI, Ziff-Werman B. Ethical considerations in the relief of cancer pain. Support Care Cancer 2023; 31:414. [PMID: 37351702 DOI: 10.1007/s00520-023-07868-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/07/2023] [Indexed: 06/24/2023]
Abstract
The management of pain for patients with cancer and cancer survivors is a critical clinical task that involves a multitude of ethical issues at almost every phase of the cancer experience. This review is divided into three sections: In the first, we address rights and duties in the relief of pain from the perspective of patients, clinicians, health care institutions and organizations, and public policy. This section includes a detailed description of issues and duties in relation to opioid misuse and addiction. In the second section, we discuss the ethical consideration of therapeutic planning. The final section addresses ethical considerations in the management of pain at the end of life including a detailed discussion regarding ethical issues relating to the use of palliative sedation as a clinical intervention of last resort.
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Yusufov M, McHugh RK, Greer JA, Dalrymple K, Sannes T, Braun IM, Tulsky J, Pirl W. An acceptance and commitment therapy-based intervention for opioid use disorder risk in individuals with cancer: A treatment development study. JOURNAL OF CONTEXTUAL BEHAVIORAL SCIENCE 2023; 28:226-234. [PMID: 37333769 PMCID: PMC10270682 DOI: 10.1016/j.jcbs.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
This paper describes the iterative development of an evidence-based behavioral intervention for individuals with cancer at risk for opioid use disorder, using the National Institutes of Health Stage Model for Behavioral Intervention Development. Adult patients with cancer from an outpatient palliative care clinic at an academic cancer center, with moderate to high risk of opioid misuse, were enrolled in a treatment development study that aimed to increase psychological flexibility. In this intervention, psychological flexibility is the posited mechanism of change for reduction of opioid use disorder risk. Patients completed baseline (pre-intervention) assessments, a six-session behavioral intervention based in Acceptance and Commitment Therapy, post-intervention assessments, and a semi-structured exit interview. Ten patients with moderate to high risk of opioid misuse completed the intervention. Patients rated the intervention as highly acceptable and were generally highly satisfied. Patients reported finding the coping skills helpful (e.g., mindfulness, cognitive defusion) and reported a preference for more sessions. These treatment development efforts have implications for the development and design of acceptance- and mindfulness-based, targeted interventions for individuals with cancer, receiving palliative care and at risk for opioid use disorder. Specifically, this six-session behavioral intervention to increase psychological flexibility was acceptable to patients and ready to be studied in a pilot RCT.
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Affiliation(s)
- Miryam Yusufov
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School
| | | | | | | | - Timothy Sannes
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School
| | - Ilana M Braun
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School
| | - James Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School
| | - William Pirl
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School
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6
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Pergolizzi JV, Magnusson P, Christo PJ, LeQuang JA, Breve F, Mitchell K, Varrassi G. Opioid Therapy in Cancer Patients and Survivors at Risk of Addiction, Misuse or Complex Dependency. FRONTIERS IN PAIN RESEARCH (LAUSANNE, SWITZERLAND) 2022; 2:691720. [PMID: 35295520 PMCID: PMC8915703 DOI: 10.3389/fpain.2021.691720] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 10/13/2021] [Indexed: 12/21/2022]
Abstract
A clinical conundrum can occur when a patient with active opioid use disorder (OUD) or at elevated risk for the condition presents with cancer and related painful symptoms. Despite earlier beliefs that cancer patients were relatively unaffected by opioid misuse, it appears that cancer patients have similar risks as the general population for OUD but are more likely to need and take opioids. Treating such patients requires an individualized approach, informed consent, and a shared decision-making model. Tools exist to help stratify patients for risk of OUD. While improved clinician education in pain control is needed, patients too need to be better informed about the risks and benefits of opioids. Patients may fear pain more than OUD, but opioids are not always the most effective pain reliever for a given patient and some patients do not tolerate or want to take opioids. The association of OUD with mental health disorders (dual diagnosis) can also complicate delivery of care as patients with mental health issues may be less adherent to treatment and may use opioids for “chemical coping” as much as for pain control.
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Affiliation(s)
| | - Peter Magnusson
- Centre for Research & Development, Uppsala University, Uppsala, Sweden.,Department of Medicine, Cardiology Research Unit, Karolinska Institutet, Stockholm, Sweden
| | - Paul J Christo
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | | | - Frank Breve
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, PA, United States
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Ayoub NM, Jibreel M, Nuseir K, Al-Taani GM. A Survey of Knowledge and Barriers of Healthcare Professionals toward Opioid Analgesics in Cancer Pain Management. Int J Clin Pract 2022; 2022:1136430. [PMID: 35685510 PMCID: PMC9159223 DOI: 10.1155/2022/1136430] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/28/2022] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Pain is among the most frequent and troubling symptoms in cancer patients. Despite the availability of updated treatment guidelines and effective pharmacological therapies, undertreatment of cancer pain remains a global problem. Opioids are the mainstay analgesics to treat moderate-to-severe cancer pain. The goal of this study was to assess the knowledge and barriers towards opioid analgesics for cancer pain management among healthcare professionals in Oncology Units in Jordan. METHODS A structured questionnaire was administered to healthcare professionals (consultant doctors, resident doctors, pharmacists, and nurses) at three Oncology Units in a cross-sectional study design. RESULTS A total of 201 healthcare professionals completed the questionnaire. The average age was 34.8 ± 8.1 years (range 23-58) and 49.3% of respondents were nurses. The mean score for the knowledge of opioids was 12.5 ± 3.2 out of 24 points (range 2-20). An acceptable level of knowledge was observed in 50.7% of participants, while 49.3% had poor knowledge. Knowledge items mostly answered incorrectly were related to opioid administration, pharmacology, dosing, adverse events, rotation, and toxicity. Knowledge scores were significantly higher for consultant doctors compared to pharmacists and nurses (p=0.016 and p < 0.001, respectively). Healthcare professionals who handled opioid analgesics had significantly higher mean knowledge scores than those who did not (p=0.012). Linear regression analysis revealed that being a consultant physician has an independent, statistically significant association with higher knowledge scores. Among perceived barriers to using opioids, fear of addiction by patients was the most frequently reported barrier by respondents (79.6%). Other highly recognized barriers were fear of adverse effects by patients (67.2%) and lack of training programs on opioid dosing and monitoring (63.7%). CONCLUSIONS This study revealed major gaps in the knowledge of opioids and pain management among healthcare professionals. There is an urgent need for developing innovative interventions to improve the knowledge of opioid analgesics and the understanding of pain management guidelines among healthcare professionals in Jordan.
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Affiliation(s)
- Nehad M. Ayoub
- Department of Clinical Pharmacy Faculty of Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Malak Jibreel
- Department of Clinical Pharmacy Faculty of Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Khawla Nuseir
- Department of Clinical Pharmacy Faculty of Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Ghaith M. Al-Taani
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Yarmouk University, Irbid, Jordan
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8
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Kihara A, Shimada K, Tsuneto S. How Do We Taper and Discontinue Opioids in Cancer Patients? Considerations from the Activities of a Palliative Care Team at a University Hospital. Palliat Med Rep 2021; 2:255-259. [PMID: 34927150 PMCID: PMC8675093 DOI: 10.1089/pmr.2020.0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2021] [Indexed: 11/30/2022] Open
Abstract
Background: The more the cancer treatments progress, the more the needs increase to taper and discontinue opioids in cancer patients. Furthermore, opioid dependence of cancer survivors has become a bigger problem. However, a safe opioid tapering and discontinuation method has not yet been established in cancer patients. Objective: To suggest a safe opioid tapering and discontinuation method in cancer patients. Design: We reviewed opioid type, dose, administration route, administration duration, reason for tapering and discontinuation, and presence/absence of opioid withdrawal symptoms in cancer patients whose opioids needed to be tapered and discontinued. Setting/Subjects: We recruited cancer patients referred to the palliative care team of Kyoto University Hospital-Japan whose opioids were tapered and discontinued. Measurements: Opioid withdrawal symptoms were assessed by two physicians, one nurse, and one pharmacist of palliative care team. Results: Opioids were tapered and discontinued in 25 out of 145 cancer patients (17%). Opioid withdrawal symptoms were observed in 3 of the 25 cases (12%). In withdrawal symptom cases and nonwithdrawal symptom cases, the mean maximum oral morphine-equivalent doses of opioids were 352.0 and 55.7 mg/day, and the mean administration duration of opioid were 82.3 and 28.7 days, respectively. Withdrawal symptoms occurred in patients receiving higher-dose opioids with longer administration duration and their symptoms tended to appear at approximately 10% of the maximum dose. Conclusions: We suggest that withdrawal symptoms may be prevented by using a two-stage method rather than a monotonous tapering method in cancer patients whose higher-dose opioid with longer administration duration needed to be tapered and discontinued.
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Affiliation(s)
- Ayumi Kihara
- Department of Palliative Medicine, Kyoto Min-iren Asukai Hospital, Kyoto, Japan
| | - Kazuki Shimada
- Department of Palliative Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Satoru Tsuneto
- Department of Palliative Medicine, Kyoto University Hospital, Kyoto, Japan.,Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Mercadante S, Coluzzi F. Factors Influencing Pain Expression in Patients with Cancer: An Expert Opinion. Pain Ther 2021; 10:765-775. [PMID: 34014529 PMCID: PMC8586270 DOI: 10.1007/s40122-021-00272-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/07/2021] [Indexed: 11/05/2022] Open
Abstract
Pain is a multidimensional experience that requires an appropriate assessment, and simple numbering may not be enough for the different components that are involved in the clinical expression. In consideration of the subjectivity of the symptom, each assessment should start from the way in which the patients perceive the pain and from how they deal with it. Some factors related to individual patient characteristics may make pain management difficult because of interference with the clinical pain expression. These factors may amplify the reporting of pain. Cognitive disorders and psychological distress seem to strongly influence pain expression and may render the analgesic treatment more difficult. Aberrant behaviors, such as alcoholism, smoking, and opioid misuse, may play a role, although geographic differences were found in terms of prevalence of the phenomenon, especially in some countries. Finally, the assessment of patients' expectation and the meaning of the personal feeling of changes in pain intensity provide new concepts in pain assessment, which may allow better personalization of the analgesic therapy. A modern pain assessment should include a multitude of factors influencing the phenotype of pain.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit and Pain Relief and Supportive-Palliative Care Unit, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
| | - Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
- Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Chua IS, Fratt E, Ho JJ, Roldan CS, Gundersen DA, Childers J. Primary Addiction Medicine Skills for Hospice and Palliative Medicine Physicians: A Modified Delphi Study. J Pain Symptom Manage 2021; 62:720-729. [PMID: 33677071 DOI: 10.1016/j.jpainsymman.2021.02.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 01/22/2023]
Abstract
CONTEXT Hospice and palliative medicine (HPM) physicians frequently care for patients with substance use disorders (SUDs), but there is no consensus on which primary addiction medicine (AM) skills are essential. OBJECTIVES Identify key primary AM skills that physicians should acquire during an ACGME-accredited HPM fellowship program. METHODS A modified Delphi study consisting of 18 experts on SUD in HPM and medical education. A literature review and expert input identified initial AM skills. In three Delphi rounds, participants rated each skill on a nine-point scale from "not at all important to include" to "crucial to include." We calculated medians (IQRs), analyzed panelists' comments, and grouped skills using the RAND / UCLA appropriateness method. RESULTS Among 62 proposed AM skills, 53 skills were rated as appropriate to include (38 of which achieved agreement), and nine skills were rated as uncertain. AM skills most relevant to HPM included 1) defining chemical coping, median 8.5 (IQR 2); 2) balancing life expectancy with risks of opioid use for patients with SUD, 9 (IQR 0); 3) explaining best practices to dispose unused opioids postmortem, 8 (IQR 2); 4) managing pain for hospice patients with SUD, 9 (IQR 0.75); and 5) partnering with hospice to manage patients on methadone and buprenorphine, 9 (IQR 2). Experts did not achieve consensus on whether HPM physicians should be encouraged to learn to prescribe buprenorphine for patients with opioid use disorder, 6 (IQR 3). CONCLUSION HPM fellowships should consider incorporating the primary AM skills identified in this study in their curricula.
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Affiliation(s)
- Isaac S Chua
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
| | - Ellie Fratt
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - J Janet Ho
- Division of Palliative Medicine, University of California San Francisco, San Francisco, California, USA
| | - Claudia S Roldan
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Daniel A Gundersen
- Division of Population Health Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Julie Childers
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Massachusetts, USA; Section for Treatment, Research, and Education in Addiction Medicine, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Massachusetts, USA
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11
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Noel CW, Eskander A, Sutradhar R, Mahar A, Vigod SN, Isenberg-Grzeda E, Bolton J, Deleemans J, Chan WC, Vasdev R, Zuk V, Haas B, Mason S, Coburn NG, Hallet J. Incidence of and Factors Associated With Nonfatal Self-injury After a Cancer Diagnosis in Ontario, Canada. JAMA Netw Open 2021; 4:e2126822. [PMID: 34559226 PMCID: PMC8463938 DOI: 10.1001/jamanetworkopen.2021.26822] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE Psychological distress is a key component of patient-centered cancer care. While a greater risk of suicide among patients with cancer has been reported, more frequent consequences of distress, including nonfatal self-injury (NFSI), remain unknown. OBJECTIVE To examine the risk of NFSI after a cancer diagnosis. DESIGN, SETTING, AND PARTICIPANTS This population-based retrospective cohort study used linked administrative databases to identify adults diagnosed with cancer between 2007 and 2019 in Ontario, Canada. EXPOSURES Demographic and clinical factors. MAIN OUTCOMES AND MEASURES Cumulative incidence of NFSI, defined as emergency department presentation of self-injury, was computed, accounting for the competing risk of death from all causes. Factors associated with NFSI were assessed using multivariable Fine and Gray models. RESULTS In total, 806 910 patients met inclusion criteria. The mean (SD) age was 65.7 (14.3) years, and 405 161 patients (50.2%) were men. Overall, 2482 (0.3%) had NFSI and 182 (<0.1%) died by suicide. The 5-year cumulative incidence of NFSI was 0.27% (95% CI, 0.25%-0.28%). After adjusting for key confounders, prior severe psychiatric illness, whether requiring inpatient care (subdistribution hazard ratio [sHR], 12.6; 95% CI, 10.5-15.2) or outpatient care (sHR, 7.5; 95% CI, 6.5-8.8), and prior self-injury (sHR, 6.6; 95% CI, 5.5-8.0) were associated with increased risk of NFSI. Young adults (age 18-39 years) had the highest NFSI rates relative to individuals aged 70 years or older (sHR, 5.4; 95% CI, 4.5-6.5). The magnitude of association between prior inpatient psychiatric illness and NFSI was greatest for young adults (sHR, 17.6; 95% CI, 12.0-25.8). Certain cancer subsites were also associated with increased risk, including head and neck cancer (sHR, 1.5; 95% CI, 1.2-1.9). CONCLUSIONS AND RELEVANCE In this study, patients with cancer had a higher incidence of NFSI than suicide after diagnosis. Younger age, history of severe psychiatric illness, and prior self-injury were independently associated with risk of NFSI. These exposures appeared to act synergistically, placing young adults with a prior mental health history at the greatest risk of NFSI. These factors should be used to identify at-risk patients.
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Affiliation(s)
- Christopher W. Noel
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Ontario, Canada
| | - Antoine Eskander
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Ontario, Canada
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Ontario, Canada
| | - Alyson Mahar
- Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Simone N. Vigod
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Ontario, Canada
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Elie Isenberg-Grzeda
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - James Bolton
- Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julie Deleemans
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Ravleen Vasdev
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Victoria Zuk
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Barbara Haas
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Ontario, Canada
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Stephanie Mason
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Ontario, Canada
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Natalie G. Coburn
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Ontario, Canada
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Julie Hallet
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Ontario, Canada
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
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12
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Lau J, Mazzotta P, Fazelzad R, Ryan S, Tedesco A, Smith AJ, Sud A, Furlan AD, Zimmermann C. Assessment tools for problematic opioid use in palliative care: A scoping review. Palliat Med 2021; 35:1295-1322. [PMID: 34000897 PMCID: PMC8267087 DOI: 10.1177/02692163211015567] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Screening for problematic opioid use is increasingly recommended in patients receiving palliative care. AIM To identify tools used to assess for the presence or risk of problematic opioid use in palliative care. DESIGN Scoping review. DATA SOURCES Bibliographic databases (inception to January 31, 2020), reference lists, and grey literature were searched to find primary studies reporting on adults receiving palliative care and prescription opioids to manage symptoms from advanced cancer, neurodegenerative diseases, or end-stage organ diseases; and included tools to assess for problematic opioid use. There were no restrictions based on study design, location, or language. RESULTS We identified 42 observational studies (total 14,431 participants) published between 2009 and 2020 that used questionnaires (n = 32) and urine drug tests (n = 21) to assess for problematic opioid use in palliative care, primarily in US (n = 38) and outpatient palliative care settings (n = 36). The questionnaires were Cut down, Annoyed, Guilty, and Eye-opener (CAGE, n = 8), CAGE-Adapted to Include Drugs (CAGE-AID, n = 6), Opioid Risk Tool (n = 9), Screener and Opioid Assessment for Patients with Pain (SOAPP; n = 3), SOAPP-Revised (n = 2), and SOAPP-Short Form (n = 5). Only two studies' primary objectives were to evaluate a questionnaire's psychometric properties in patients receiving palliative care. There was wide variation in how urine drug tests were incorporated into palliative care; frequency of abnormal urine drug test results ranged from 8.6% to 70%. CONCLUSION Given the dearth of studies using tools developed or validated specifically for patients receiving palliative care, further research is needed to inform clinical practice and policy regarding problematic opioid use in palliative care.
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Affiliation(s)
- Jenny Lau
- Division of Palliative Care, University of Toronto, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Paolo Mazzotta
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Rouhi Fazelzad
- UHN Library and Information Services, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Suzanne Ryan
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Division of Palliative Medicine, University of Toronto, Toronto, ON, Canada
| | - Alissa Tedesco
- Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Andrew J Smith
- Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Abhimanyu Sud
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Medical Psychiatry Alliance, Toronto, ON, Canada
| | - Andrea D Furlan
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Institute for Work and Health, Toronto, ON, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Division of Palliative Medicine, University of Toronto, Toronto, ON, Canada.,Division of Medical Oncology, University of Toronto, Toronto, ON, Canada
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13
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Mercadante S, Adile C, Tirelli W, Ferrera P, Penco I, Casuccio A. Aberrant opioid use behaviour in advanced cancer. BMJ Support Palliat Care 2020; 12:107-113. [PMID: 33355216 DOI: 10.1136/bmjspcare-2020-002606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/16/2020] [Accepted: 12/01/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To evaluate the presence of aberrant behaviour in a consecutive sample of patients with advanced cancer treated with opioids in a country like Italy, with its peculiar attitudes towards the use opioids. The second objective was to detect the real misuse of opioids in clinical practice. METHODS Prospective observational study in two palliative care units in Italy in a period of 6 months. At admission the Edmonton Symptom Assessment Scale, the Memorial Delirium Assessment Scale, Brief Pain Inventory (BPI) and the Hospital Anxiety Depression Scale were measured. For detecting the risk of aberrant opioid use, the Screener and Opioid Assessment for Patients With Pain (SOAAP), the Opioid Risk Tool (ORT), the Cut Down-Annoyed-Guilty-Eye Opener (CAGE) questionnaire adapted to include drug use (CAGE-AID) were used. Aberrant behaviours displayed at follow-up within 1 month were recorded. RESULTS One-hundred and thirteen patients with advanced cancer were examined. About 35% of patients were SOAPP positive. There was correlation between SOAPP, CAGE-AID and ORT. SOAPP was independently associated with a lower Karnofsky level, pain intensity, poor well-being, BPI pain at the moment. No patient displayed aberrant behaviours, despite having a moderate-high risk. CONCLUSIONS Despite a high percentage of patients showed a high risk of aberrant behaviours, no patient displayed clinical aberrant behaviours after 1 month-follow-up. This does not exempt from continuous monitoring for patients who are at risk.
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Affiliation(s)
- Sebastiano Mercadante
- Main regional center for Pain Relief and Palliative/supportive Care La Maddalena cancer Center Palermo, Palermo, Sicilia, Italy
| | - Claudio Adile
- Main regional center for Pain Relief and Palliative/supportive Care La Maddalena cancer Center Palermo, Palermo, Sicilia, Italy
| | | | - Patrizia Ferrera
- Main regional center for Pain Relief and Palliative/supportive Care La Maddalena cancer Center Palermo, Palermo, Sicilia, Italy
| | | | - Alessandra Casuccio
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Sicilia, Italy
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14
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Rousseau R, Weisberg DF, Gorero J, Parwani V, Bozzo J, Kenyon K, Smith C, Cole J, Curtis S, Forray A, Roberts JD. Utilization, financial outcomes and stakeholder perspectives of a re-organized adult sickle cell program. PLoS One 2020; 15:e0236360. [PMID: 32706825 PMCID: PMC7380627 DOI: 10.1371/journal.pone.0236360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/03/2020] [Indexed: 11/30/2022] Open
Abstract
In 2011 Yale New Haven Hospital, in response to high utilization of acute care services and widespread patient and health care personnel dissatisfaction, set out to improve its care of adults living with sickle cell disease. Re-organization components included recruitment of additional personnel; re-locating inpatients to a single nursing unit; reducing the number of involved providers; personalized care plans for pain management; setting limits upon access to parenteral opioids; and an emphasis upon clinic visits focused upon home management of pain as well as specialty and primary care. Outcomes included dramatic reductions in inpatient days (79%), emergency department visits (63%), and hospitalizations (53%); an increase in outpatient visits (31%); and a decrease in costs (49%). Providers and nurses viewed the re-organization and outcomes positively. Most patients reported improvements in pain control and life style; many patients thought the re-organization process was unfair. Their primary complaint was a lack of shared decision-making. We attribute the contrast in these perspectives to the inherent difficulties of managing recurrent acute and chronic pain with opioids, especially within the context of the imbalance in wellness, power, and privilege between persons living with sickle cell disease, predominantly persons of color and poor socio-economic status, and health care organizations and their personnel.
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Affiliation(s)
- Robert Rousseau
- Northeastern University Bouvé College of Health Sciences, Boston, MA, United States of America
| | - Daniel F. Weisberg
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Jack Gorero
- Hartford Hospital, Hartford, CT, United States of America
| | - Vivek Parwani
- Yale School of Medicine, New Haven, CT, United States of America
| | - Janis Bozzo
- Yale New Haven Health, New Haven, CT, United States of America
| | - Kathleen Kenyon
- Yale New Haven Hospital, New Haven, CT, United States of America
| | - Constance Smith
- Yale New Haven Hospital, New Haven, CT, United States of America
| | - Joanna Cole
- Yale New Haven Hospital, New Haven, CT, United States of America
| | - Susanna Curtis
- Yale School of Medicine, New Haven, CT, United States of America
| | - Ariadna Forray
- Yale School of Medicine, New Haven, CT, United States of America
| | - John D. Roberts
- Yale School of Medicine, New Haven, CT, United States of America
- * E-mail:
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15
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Kirschbaum M, Barnett T, Cross M. Experiences of over-the-counter codeine misusers and accounts of recovery: A qualitative study in Tasmania, Australia. Drug Alcohol Rev 2020; 39:879-887. [PMID: 32367599 DOI: 10.1111/dar.13081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND AIMS There is international concern about misuse of over-the-counter (OTC) codeine, yet few studies have reported the perspectives of misusers themselves. This study explored the experience of OTC codeine misuse and recovery in Tasmania, Australia. DESIGN AND METHODS Semi-structured telephone interviews were conducted with 15 self-identified long-term users of OTC codeine. The interview guide prompted responses about reasons for codeine use, positive and negative impacts, recovery, identity and codeine accessibility. Transcripts were analysed abductively using qualitative content analysis. Categories that emerged from misuser accounts were aligned to three broad temporal phases: (i) transition to misuse; (ii) growing awareness; and (iii) towards recovery. RESULTS Salient features of the misuse experience included: initial use for the self-treatment of physical pain; ongoing use to self-medicate physical pain, stress or mental health conditions; a perception of safety of OTC codeine; an insidious transition from use to misuse; growing awareness of a problem over time; support provided by family, friends and the internet; recovery through self-change; and recognition that recovery is an ongoing process. DISCUSSION AND CONCLUSIONS Knowledge and understanding of the experience of OTC codeine misuse and recovery is critical to inform and tailor approaches to prevention and intervention. The findings suggest that strategies to improve the management of pain, stress and mental health, raise self-awareness of problematic use and potential for self-change, and increase social and web-based supports, should be considered when designing health policy initiatives that aim to reduce misuse.
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Affiliation(s)
| | - Tony Barnett
- Centre for Rural Health, University of Tasmania, Launceston, Australia
| | - Merylin Cross
- Centre for Rural Health, University of Tasmania, Launceston, Australia
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16
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Anandarajah G, Mennillo HA, Rachu G, Harder T, Ghosh J. Lifestyle Medicine Interventions in Patients With Advanced Disease Receiving Palliative or Hospice Care. Am J Lifestyle Med 2020; 14:243-257. [PMID: 32477022 PMCID: PMC7232901 DOI: 10.1177/1559827619830049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 01/18/2019] [Accepted: 01/21/2019] [Indexed: 01/01/2023] Open
Abstract
Background: Lifestyle medicine interventions have the potential to improve symptom management, daily function, and quality of life (QOL) in patients with advanced or terminal disease receiving palliative or hospice care. The goal of this review is to summarize the current state of the literature on this subject. Methods: The authors used a broad search strategy to identify relevant studies, reviews, and expert opinions, followed by narrative summary of available information. Results: Four main categories of lifestyle interventions feature prominently in the palliative care literature: exercise, nutrition, stress management, and substance use. High-quality studies in this vulnerable population are relatively sparse. Some interventions show promise. However, most show mixed results or inadequate evidence. For some interventions, risks in this generally frail population outweigh the benefits. Clinical decision making involves balancing research findings, including the risks and benefits of interventions, with a clear understanding of patients' prognosis, goals of care, and current physical, emotional, and spiritual state. Achieving optimum QOL, safety, and ethical care are emphasized. Conclusions: The use of lifestyle interventions in patients receiving palliative or hospice care is a complex undertaking, requiring tailoring recommendations to individual patients. There is potential for considerable benefits; however, more research is needed.
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Affiliation(s)
- Gowri Anandarajah
- Gowri Anandarajah, MD, Office of Medical Education, Warren Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02912; e-mail:
| | - Haran Asher Mennillo
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (GA, HAM, JG)
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island (GA, GR)
- Brown University, Providence, Rhode Island (TH)
| | - Gregory Rachu
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (GA, HAM, JG)
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island (GA, GR)
- Brown University, Providence, Rhode Island (TH)
| | - Tyler Harder
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (GA, HAM, JG)
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island (GA, GR)
- Brown University, Providence, Rhode Island (TH)
| | - Jyotsna Ghosh
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (GA, HAM, JG)
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island (GA, GR)
- Brown University, Providence, Rhode Island (TH)
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17
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Miura M, Tsuruga K, Morimoto Y. A pediatric cancer patient with suspected chemical coping following high-dose opioid therapy: a case report. J Med Case Rep 2019; 13:353. [PMID: 31783905 PMCID: PMC6884815 DOI: 10.1186/s13256-019-2273-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 09/24/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chemical coping is an inappropriate method for dealing with stress through the use of opioids; it is considered the stage prior to abuse and dependence. In patients with cancer, it is important to evaluate the risk of chemical coping when using opioids. There are some pediatric opioid use-related tolerances and addictions; however, no mention of chemical coping has been found. CASE PRESENTATION We present a case of an 11-year-old Japanese boy with acute lymphocytic leukemia. After transplantation, he complained of abdominal and articular pain, which are considered as symptoms of graft-versus-host disease; thus, opioid therapy was initiated, and the dose was gradually increased for pain management, resulting in a high dose of 2700 μg/day of fentanyl (4200-4700 μg/day including the rescue dose). After switching from fentanyl to oxycodone injections, he continued to experience pain, and there was no change in the frequency of oxycodone rescue doses. Physically, his pain was considered to have alleviated; thus, there was the possibility of mental anxiety resulting in the lowering of pain threshold and the possibility of chemical coping. Mental anxiety and stress with progress through schooling was believed to have resulted in chemical coping; thus, efforts were made to reduce the boy's anxiety, and opioid education was provided. However, dose reduction was challenging. Ultimately, with guidance from medical care providers, the opioid dose was reduced, and the patient was successfully weaned off opioids. CONCLUSIONS When chemical coping is suspected in pediatric patients, after differentiating from pseudo-addiction, it might be necessary to restrict the prescription for appropriate use and to provide opioid education while taking into consideration the emotional background of the patient that led to chemical coping.
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Affiliation(s)
- Mototsugu Miura
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Hokkaido, Japan.
| | | | - Yuji Morimoto
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
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18
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Arthur J, Bruera E. Balancing opioid analgesia with the risk of nonmedical opioid use in patients with cancer. Nat Rev Clin Oncol 2019; 16:213-226. [PMID: 30514978 DOI: 10.1038/s41571-018-0143-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The current opioid crisis has brought renewed attention and scrutiny to opioid prescriptions. When patients receiving opioid therapy for pain engage in nonmedical opioid use (NMOU) or diversion, untoward consequences can occur. New evidence suggests that patients with cancer might be at a higher risk of NMOU than was previously thought, but clinical evidence still supports the use of opioid analgesics as the gold standard to treat cancer-related pain, creating a dilemma in patient management. Clinicians are encouraged to adopt a universal precautions approach to patients with cancer receiving opioids, which includes screening all patients; discussing the risks, benefits, adverse effects and alternatives of opioid therapy; and providing education on safe use, storage and disposal. Use of urine drug tests, prescription drug monitoring programmes and close observation of behaviours related to opioid use help to ensure treatment adherence, detect NMOU and support therapeutic decision-making. These measures can optimize the risk-benefit ratio while supporting safe opioid use. In this Review, we examine the role of opioids in cancer pain, the risk of substance use disorder and methods to achieve the right balance between the two in order to ensure safe opioid use.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA.
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19
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Arthur J, Reddy A. Opioid Prescribing in an Opioid Crisis: What Basic Skills Should an Oncologist Have Regarding Opioid Therapy? Curr Treat Options Oncol 2019; 20:39. [PMID: 30937544 DOI: 10.1007/s11864-019-0636-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OPINION STATEMENT Although clinical evidence supports the use of opioids for cancer-related pain, doing so amidst the current opioid crisis remains a challenge. A proportion of opioid-related deaths in the USA are attributable to prescription opioids, which implicates health care providers as one of the major contributors. It is therefore even more important now for all clinicians to follow safe and effective opioid prescribing practices. Oncologists are often in the frontline of cancer pain management. They are encouraged to use validated tools to screen all patients receiving opioids for high risk behaviors. Those identified as high risk for potential abuse of opioids should be monitored closely. When aberrant behavior is detected, the clinician will need to openly discuss the issue and its possible implications. Oncologists may then implement measures such as limiting the dose and quantity of opioids prescribed, shortening interval between follow-ups for refills to allow for increased monitoring, setting boundaries/limitations, weaning off opioid analgesics, or/and referring to a pain or palliative medicine or drug addiction expert for co-management when necessary. These efforts may aid oncologists in safely managing cancer pain in the environment of national opioid crisis.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative, Rehabilitation, & Integrative Medicine, The University of Texas MD Anderson Cancer, Unit 1414, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, & Integrative Medicine, The University of Texas MD Anderson Cancer, Unit 1414, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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20
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston
| | - Joseph Arthur
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston
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21
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Dalal S, Bruera E. Pain Management for Patients With Advanced Cancer in the Opioid Epidemic Era. Am Soc Clin Oncol Educ Book 2019; 39:24-35. [PMID: 31099619 DOI: 10.1200/edbk_100020] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Use of opioids for the treatment of pain is necessary for the majority of patients with advanced cancer, however its use has become challenging in the face of the opioid epidemic and the emerging evidence that patients with cancer are also at risk for nonmedical opioid use. This article proposes an assessment and treatment plan that incorporates universal screening with monitoring for all patients with cancer who are considered for opioid treatment to assess their risk for opioid misuse and harm. Timely identification with appropriate management, including referral of at-risk patients, will allow oncology professionals to optimize the risk-to-benefit and support the safe use of opioids for patients with cancer.
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Affiliation(s)
- Shalini Dalal
- 1 From the Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eduardo Bruera
- 1 From the Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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22
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Castañeda AM, Lee CS, Kim YC, Lee D, Moon JY. Addressing Opioid-Related Chemical Coping in Long-Term Opioid Therapy for Chronic Noncancer Pain: A Multicenter, Observational, Cross-Sectional Study. J Clin Med 2018; 7:E354. [PMID: 30322212 PMCID: PMC6210168 DOI: 10.3390/jcm7100354] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 10/10/2018] [Accepted: 10/13/2018] [Indexed: 11/30/2022] Open
Abstract
Opioid consumption has increased worldwide, which carries the risk of opioid use disorder (OUD). However, the literature on OUD and opioid-related chemical coping (OrCC) in chronic noncancer pain (CNCP) is heterogeneous, with most studies conducted in the United States. We performed a multicenter, observational, cross-sectional study to address OrCC in long-term opioid therapy (LtOT) for CNCP in South Korea. The objectives were to determine the frequency and predictors of OrCC. We included 258 patients. Among them, fifty-five (21%) patients showed OrCC. The sample had high pain catastrophizing (≥30 points; 66%), moderate-severe insomnia (≥15 points; 63%), low resilience (68 points), and high suicidal ideation (67%). OrCC patients had greater pain interference (85.18% vs. 58.28%, p = 0.017) and lower satisfaction with the LtOT (56.4% vs. 78.3%, p = 0.002). In multivariable analysis, alcohol abuse (OR = 6.84, p = 0.001), prescription drugs abuse (OR = 19.32, p = 0.016), functional pain (OR = 12.96, p < 0.001), head and neck pain (OR = 2.48, p = 0.039), MEDD (morphine equivalent daily dose) ≥ 200 mg/day (OR = 3.48, p = 0.006), and ongoing litigation (OR = 2.33, p = 0.047) were significant predictors of OrCC. In conclusion, the break-out of OrCC in CNCP in South Korea was comparable to those in countries with high opioid consumption, such as the United States, regardless of the country's opioid consumption rate.
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Affiliation(s)
- Anyela Marcela Castañeda
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital College of Medicine, 101Daehak-ro, Jongno-gu, Seoul 03080, Korea.
| | - Chang-Soon Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital College of Medicine, 101Daehak-ro, Jongno-gu, Seoul 03080, Korea.
| | - Yong-Chul Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital College of Medicine, 101Daehak-ro, Jongno-gu, Seoul 03080, Korea.
| | - Dasom Lee
- Department of Psychiatry, Seoul National University Hospital College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea.
| | - Jee Youn Moon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital College of Medicine, 101Daehak-ro, Jongno-gu, Seoul 03080, Korea.
- Department of Integrated Cancer Care Center, Seoul National University Cancer Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea.
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23
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Gómez-del Valle MC, Zertuche-Maldonado T, Bruera E. Compensación química y adicción a opioides: evidencia, valoración de riesgo y manejo en pacientes con cuidados paliativos. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.medipa.2016.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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24
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Yennurajalingam S, Edwards T, Arthur JA, Lu Z, Najera J, Nguyen K, Manju J, Kuriakose L, Wu J, Liu D, Williams JL, Reddy SK, Bruera E. Predicting the risk for aberrant opioid use behavior in patients receiving outpatient supportive care consultation at a comprehensive cancer center. Cancer 2018; 124:3942-3949. [DOI: 10.1002/cncr.31670] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 04/04/2018] [Accepted: 06/11/2018] [Indexed: 01/18/2023]
Affiliation(s)
- Sriram Yennurajalingam
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Tonya Edwards
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Joseph A. Arthur
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Zhanni Lu
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - John Najera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Kristy Nguyen
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Joy Manju
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Leela Kuriakose
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Jimin Wu
- Department of Quantitative Sciences; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Diane Liu
- Department of Biostatistics; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Janet L. Williams
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Suresh K. Reddy
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
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25
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Arthur J, Hui D. Safe Opioid Use: Management of Opioid-Related Adverse Effects and Aberrant Behaviors. Hematol Oncol Clin North Am 2018; 32:387-403. [PMID: 29729776 DOI: 10.1016/j.hoc.2018.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Opioids are highly effective for cancer pain but are associated with multiple adverse effects and risk of addiction. This article provides a synopsis on the management of various opioid-related adverse effects and strategies to minimize aberrant opioid use in patients who have cancer. Many adverse effects can be effectively managed. Some patients on chronic opioid therapy may demonstrate aberrant behaviors suggestive of opioid misuse or diversion. Through intensive education, longitudinal monitoring, early identification, and timely management, clinicians can optimize the risk to benefit ratio to support safe opioid use.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Unit 1414, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Unit 1414, 1515 Holcombe Boulevard, Houston, TX 77030, USA; Department of General Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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Abstract
Opioid analgesia is a mainstay of the treatment of cancer pain. Treatment of pain in patients with cancer with an ongoing substance abuse disorder can be difficult. We report the ethical challenges of treating a patient with cancer with a concomitant substance abuse disorder in an outpatient palliative care setting. We present an analysis of ethical considerations for the palliative care physician and strategies to aid in the successful treatment of such patients. We argue that there are select patients with cancer for whom exclusion from treatment with opioid therapy is warranted if their health is endangered by prescription of these medications.
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Affiliation(s)
- Leanne K. Jackson
- Michael E. DeBakey Veterans Affairs Medical Center; Baylor College of Medicine, Houston, TX
| | - Syed N. Imam
- Michael E. DeBakey Veterans Affairs Medical Center; Baylor College of Medicine, Houston, TX
| | - Ursula K. Braun
- Michael E. DeBakey Veterans Affairs Medical Center; Baylor College of Medicine, Houston, TX
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27
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Arthur JA, Edwards T, Lu Z, Reddy S, Hui D, Wu J, Liu D, Williams JL, Bruera E. Frequency, predictors, and outcomes of urine drug testing among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic. Cancer 2016; 122:3732-3739. [PMID: 27509305 DOI: 10.1002/cncr.30240] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/01/2016] [Accepted: 07/01/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND Data are limited on the use and outcomes of urine drug tests (UDTs) among patients with advanced cancer. The main objective of this study was to determine the factors associated with UDT ordering and results in outpatients with advanced cancer. METHODS A retrospective chart review was conducted of 1058 patients who attended an outpatient supportive care clinic from March 2014 to November 2015. Sixty-one patients who were receiving chronic opioid therapy and underwent UDTs were identified. A control group of 120 patients who did not undergo UDTs was selected for comparison. RESULTS Sixty-one of 1058 patients (6%) underwent UDTs, and 33 of 61 patients (54%) had abnormal results. Multivariate analysis indicated that the odds ratio for UDT ordering was 3.9 in patients who had positive Cut Down, Annoyed, Guilty, and Eye Opener (CAGE) questionnaire results (P = .002), 4.41 in patients aged < 45 years (P < .001), 5.58 in patients who had moderate-to-severe pain (Edmonton Symptom Assessment Scale pain scores ≥4; P < .001), 0.27 in patients with advanced-stage cancer, (P = .008), and 0.25 in patients who had moderate-to-severe fatigue (P = .001). Among 52 abnormal UDT results in 33 patients, the most common opioid findings were prescribed opioids absent in urine (14 of 52 tests; 27%) and unprescribed opioids in urine (13 of 52 tests; 25%). CONCLUSIONS UDTs were used infrequently among outpatients with advanced cancer who were receiving chronic opioid therapy. Younger age, positive CAGE questionnaire results, early stage cancer or no evidence of disease status, higher pain intensity, and lower fatigue scores were significant predictors of UDT ordering. More than 50% of UDT results were abnormal. More research is necessary to better characterize aberrant opioid use in patients with advanced cancer. Cancer 2016;122:3732-9. © 2016 American Cancer Society.
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Affiliation(s)
- Joseph A Arthur
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Tonya Edwards
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Zhanni Lu
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Suresh Reddy
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Jimin Wu
- Department of Quantitative Sciences, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Diane Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Janet L Williams
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
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28
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Carmichael AN, Morgan L, Del Fabbro E. Identifying and assessing the risk of opioid abuse in patients with cancer: an integrative review. Subst Abuse Rehabil 2016; 7:71-9. [PMID: 27330340 PMCID: PMC4898427 DOI: 10.2147/sar.s85409] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The misuse and abuse of opioid medications in many developed nations is a health crisis, leading to increased health-system utilization, emergency department visits, and overdose deaths. There are also increasing concerns about opioid abuse and diversion in patients with cancer, even at the end of life. Aims To evaluate the current literature on opioid misuse and abuse, and more specifically the identification and assessment of opioid-abuse risk in patients with cancer. Our secondary aim is to offer the most current evidence of best clinical practice and suggest future directions for research. Materials and methods Our integrative review included a literature search using the key terms “identification and assessment of opioid abuse in cancer”, “advanced cancer and opioid abuse”, “hospice and opioid abuse”, and “palliative care and opioid abuse”. PubMed, PsycInfo, and Embase were supplemented by a manual search. Results We found 691 articles and eliminated 657, because they were predominantly non cancer populations or specifically excluded cancer patients. A total of 34 articles met our criteria, including case studies, case series, retrospective observational studies, and narrative reviews. The studies were categorized into screening questionnaires for opioid abuse or alcohol, urine drug screens to identify opioid misuse or abuse, prescription drug-monitoring programs, and the use of universal precautions. Conclusion Screening questionnaires and urine drug screens indicated at least one in five patients with cancer may be at risk of opioid-use disorder. Several studies demonstrated associations between high-risk patients and clinical outcomes, such as aberrant behavior, prolonged opioid use, higher morphine-equivalent daily dose, greater health care utilization, and symptom burden.
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Affiliation(s)
- Ashley-Nicole Carmichael
- School of Pharmacy, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Laura Morgan
- School of Pharmacy, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Egidio Del Fabbro
- Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
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